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' SAN JOAQUIN LOCAL HEALTH- DISTRICT _ <br /> FOP. OFFICE USE W 1601 E. Hazelton Aver` Stockton Calif. <br /> Telephone: (209) ' 466-6781 <br /> /l�F-2 <br /> APPLICATION FOR WELL CONSTRUCTION OR PUMP PERMIT Permit%/ <br /> THIS PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Date Issued g 77 <br /> (Complete In Triplicate) lS <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct. <br /> and/or install the work herein described. This application is made in compliance with San Joaquin <br /> r County Ordinance'N0 1862 and the Rules and Regulations of the San Joaquin Local Health District. <br /> JOB ADDRESS/LOCATION. . .., 15525 S. Cotta e Manteca CENSUS TRACT <br /> Owner's Name EultsLMor an Phone 823-3597 <br /> Address 15525 'S'.-Cottage ,, City Manteca <br /> Contractor's Name t <br /> License # Phone <br /> TYPE_OF_.WORK._(.Che.ck).: NE -WEL --- 4 <br /> � <br /> _ <br /> PUMP INSTALLATION / / "PUMP REPAIR/ / PUMP REPLACEMENT <br /> Other <br /> DISTANCE TO NEAREST: SEPTIC TANK 82► SEWER LINES 421 PIT PRIVY <br /> SEWAGEI�SPO AL FIELD <br /> �0! CESSPOOL/SEEPAGE PIT OTHER <br /> . �BOPFTX jp''r"AT -DD] .ST.LG-�aIELL PUBLIC DOMESTIC WELL - <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Industrial Cable Tool Dia. of Well Excavation <br /> Domestic/private k—Drilled Dia, of Well Casing <br /> `9 <br /> a . A—Domestic/pub#lic .ri -,I -Casing of�-Casing <br />�Y�� Irrigation � ` �— .... � <br /> rave Pack Depth' o€ Gro 1 <br /> Cathodic Pro11tection RyF�otary Type of GroN ! ; <br /> Disposal Other Other Information <br /> Geophysicalt <br /> Surface Seal Installed By: j <br /> PUMP INSTALLATION Contractor `J <br /> H.P. <br /> PUMP REPLACEMENT: /`' teI u <br /> _= <br /> PUMP REPAIR: '�r.....+ <br /> / / State.Work Done !���" y <br /> 1 � <br /> ac.a4.-161 &L 7� � <br /> SiRUCTION OF WELL -Well Diameter <br /> i , Approxi ate Dep, hh a54 i <br /> Descr,ibe,�Mate.r <br /> I hereby agree to comply with all laws and regulations of the San Joaquin Local Health District <br /> and the State of California- pertaining to or regulating Jell construction. Within FIFTEEN DAYS <br /> after completion of my work on a new well, I will fvie� sli the San Joaquin Local Health District a , <br /> WELL DRILLERS REPORT of the well and notify them befte' putting the -well in use. The above <br /> information is true to the best of my knowledge and be-.idf. I WILL CALL FOR A GROUT INSPECTION <br /> PRIOR TO GR TING AND A FLNjkl, INSPECTION. <br /> SIGNED i i I TITLE <br /> (DRAW PLOT PLAN ON R RSE SIDE) <br /> PHASE I <br /> FOR DEPARTMENT VStE ONLY <br /> € � <br /> APPLICATION ACCEPTED BY DATEO Q <br /> �- <br /> ADDITIONAL COMMENTS: � f <br /> PHASE II GROUT INSPECTION � � PHASE III/FINAL INSPECTION <br /> INSPECTION BY DATE INSHCTION BY DATE <br /> y,E-Ael 42k-__ Rev. 1-74..: _ x 1/Z 7 2M ]` .� <br />